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J Thorac Cardiovasc Surg 2002;123:1173-1176
© 2002 The American Association for Thoracic Surgery
General Thoracic Surgery (GTS) |
From the University of Cincinnati, Cincinnati, Ohio,a and the University of Arkansas for Medical Sciences, Little Rock, Ark.b
Received for publication Dec 11, 2001. Revisions requested Dec 11, 2001; revisions received Dec 19, 2001. Accepted for publication Jan 2, 2002. Address for reprints: Abdul Rahman Jazieh, MD, MPH, The Barrett Center for Cancer, Hematology/Oncology, ML 0501, 234 Goodman Ave, Cincinnati, OH 45267-0501 (E-mail: jaziehar{at}uc.edu).
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Abstract |
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 Top Abstract IntroductionPatients and methodsReferences |
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Introduction |
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TopAbstractIntroductionPatients and methodsReferences |
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1 A 5-year survival of less than 15%, combined with the high incidence, makes lung cancer the leading cause of cancer deaths in the United States. Different therapeutic modalities are used in the management of lung cancer, depending on the tumor stage and the patient's clinical status.
Surgical resection remains the preferred therapeutic modality for early stages of non-small cell lung cancer (NSCLC), especially stages I and II, yet one third to one half of these patients die within 5 years of diagnosis. 2-5 Furthermore, many patients with early stages of NSCLC do not undergo tumor resection because of comorbidities or patient or physician preference. Patients who are not treated with surgical intervention usually have worse outcomes. Therefore the reasons for disparities in the treatment modality should always be revisited, especially in light of recent advances in therapeutic interventions.
This article reports the disparities in undergoing surgical resection for stage I and II NSCLC and the differences between patients treated with surgical resection and those who did not have an operation.
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Patients and methods |
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TopAbstractIntroductionPatients and methodsReferences |
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Study design
Data were collected by means of a retrospective review of medical records, tumor registry records, pathology reports and slides, and radiology reports. The data collected included patient characteristics, such as age, race, sex, date of diagnosis, tumor site, type of treatment, type of relapse or recurrence, and cause of death. Other tumor data collected included histologic subtype and grade, tumor margins, tumor size, number of lymph nodes sampled, number of positive lymph nodes, and pathologic TNM staging for patients who underwent an operation. For patients who did not undergo an operation, the clinical staging was used. Clinical staging included computed tomographic scanning of the chest in all patients and computed tomographic scanning of the brain, liver, and adrenals and bone scanning when clinically indicated. Hemoglobin level, albumin level, and forced expiratory volume in 1 second (FEV1) at the time of diagnosis were also included.
Statistical analysis
Patient demographics and medical characteristics were summarized with descriptive statistics (ie, percentages, medians, and ranges). Overall survival estimates for each group were obtained by using the Kaplan-Meier (product-limit) methodology, and survival distributions were compared by using log-rank tests. Demographic, clinical, laboratory, and pathologic factors were compared between the 2 groups. Factors significantly associated with the outcome were included in a Cox proportional hazards model. All analyses were performed with SAS/STAT software, version 7 (SAS Institute Inc, Cary, NC). A comparison between the characteristics of the group of patients undergoing surgical resection and the group of patients not undergoing resection was conducted by using a logistic regression model to determine significant differences. Significant variables were entered into a multivariate model analysis to identify the interaction between these variables.
Results
Five hundred fifty-one patients were included in this study. The median age of these patients was 67 years (range, 39-83 years), 89% were men (which was a result of the large proportion of VA patients), and 87% were white. Median follow-up was 24 months (range, 1-109 months). Patient characteristics are listed in Table 1. Four hundred fifty-five (82.6%) patients underwent surgical resection of their tumors, and 96 (17.4%) patients did not undergo surgical resection. The reasons for not undergoing an operation were poor pulmonary function test results (n = 70), debilitating medical problems (n = 15), and patient refusal (n = 11). Of the group not undergoing an operation, 70 patients received no treatment for their cancer. The remaining 26 patients had various treatments, including chemotherapy in 12 patients, radiation therapy in 2 patients, and combined chemotherapy and radiation in 13 patients. The comparison between the group undergoing an operation and the group not undergoing an operation revealed that older patients (>65 years) were less likely to undergo surgical intervention compared with younger patients (79% vs 87%, P < .02). In addition, women were less likely to receive surgical treatment than men (72% vs 84%, P < .02; Table 2).
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2,6
Elderly patients are less likely to receive potentially curative surgical treatment for different cancers, 7 which might be due to comorbidities and many other socioeconomic factors. Age disparity was apparent in our study, with fewer operations performed on older patients, leading to worse outcomes in these patients. Although age should not be a reason for offering less than standard therapy to patients, aggressive invasive therapy might not be possible in many elderly patients. 8 The resection rate in our older group compares favorably with that in the reported literature. The evolution of video-assisted surgery and lung volume-reducing surgery might increase the number of elderly patients undergoing surgical resection.
Racial disparities in the management of cancers have been reported. For example, African Americans were reported to have less operations for colorectal cancers, even after adjusting for age, comorbidities, and tumor stage. 9 The reasons for racial disparities might be due in part to patient preference or difficulty in communicating and not primarily because of racial discrimination. 10-12 However, reports of racial disparities in the management of early-stage NSCLC focused on elderly patients (Medicare data) and did not include other important demographic and clinical factors. 6,13 In this study the apparent racial disparity in the univariate analysis was not an independent predictor of treatment when adjusted for age, pulmonary function test results, and hemoglobin levels. This means, at least in this study, that there are other reasons for racial disparity. Furthermore, overall survival was similar for both races, which also further confirmed the lack of significant racial discrimination.
Our results did not show any sex-based difference in the management of these patients and no difference in survival between men and women.
As expected, patients with poor pulmonary function test results were less likely to undergo an operation. The use of volume-reduction surgery and video-assisted surgery also might increase the number of patients with limited pulmonary function undergoing surgical treatment.
Anemia was reported to be an independent prognostic factor for patients with stage I and II NSCLC who underwent surgical resection. 14 In this study patients with anemia also seemed to have less chance of undergoing an operation and shorter survival.
Finally, disparity in the management of cancer is complicated by various demographic, socioeconomic, and clinical factors. Physicians are encouraged to look at the patterns of their practice to minimize any possible remediable disparity.
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Acknowledgments |
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TopAbstractIntroductionPatients and methodsReferences |
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  F. Farjah, D. R. Flum, T. K. Varghese Jr, R. G. Symons, and D. E. Wood Surgeon Specialty and Long-Term Survival After Pulmonary Resection for Lung Cancer Ann. Thorac. Surg., April 1, 2009; 87(4): 995 - 1006. [Abstract] [Full Text] [PDF]
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